Management of Arteriovenous Fistula Thrombosis

Introduction to Management

The American College of Radiology recommends endovascular techniques, including mechanical thrombectomy and thrombolysis with angioplasty of underlying stenosis, as first-line treatment for arteriovenous fistula thrombosis, with surgical thrombectomy reserved for specific cases 1, 2

Thrombosed fistulae should be treated as soon as possible after detection to increase the likelihood of successful restoration and avoid temporary catheter placement 3
Initial evaluation should include assessment of the location and extent of thrombosis through clinical examination and imaging 4
Treatment selection depends on local expertise and available resources 4, 5

Endovascular management is preferred as first-line therapy over surgical techniques for most AV fistula thromboses, with success rates greater than 90% 2
Options include mechanical thrombectomy, pharmacologic thrombolysis, combination of mechanical and pharmacologic approaches, and balloon angioplasty of underlying stenosis 2, 4
Fistulography must be performed to identify and correct underlying stenosis, which is present in up to 85% of thrombosis cases 6

Surgical thrombectomy is performed using a Fogarty thrombectomy catheter with retrograde digital expression of thrombotic material, and is preferred for forearm AVFs with juxta-anastomotic stenoses 5
Surgery is also considered for cases where endovascular techniques have failed 2

For juxta-anastomotic stenoses in forearm AVFs, surgical thrombectomy with placement of new anastomosis is preferred 5
For more proximal/central thromboses, endovascular techniques are preferred 5

AVF function may be successfully reestablished up to one week after thrombosis occurs, but treatment should be initiated as soon as possible, with early intervention recommended to maximize success rates 2, 5

Technical success rates for endovascular techniques are 75-94% 2
Primary patency rates after successful intervention are 30-40% at 90 days for percutaneous techniques, and approximately 50% at 6 months and 20% at 1 year for surgical techniques 6
Regular monitoring for recurrent stenosis or thrombosis is essential 4

Failure to identify and treat underlying stenosis will result in rapid repeat thrombosis 6
If thrombosis recurs more than twice within a month, consider hypercoagulability testing and vascular surgery consultation for access revision 2
If restoration fails, a tunneled dialysis catheter may be needed temporarily while planning for a new access creation 2